Effect of goal-directed fluid therapy on renal function in critically ill patients: a systematic review and meta-analysis.

OBJECTIVE: To evaluate whether goal-directed fluid therapy (GDFT) reduces the risk of renal injury in critical illness. METHODS: MEDLINE via PubMed, EMBASE, CENTRAL and CBM was searched from inception to 13 March 2022, for studies comparing the effect of GDFT with usual care on renal function in critically ill patients. GDFT was defined as a protocolized intervention based on hemodynamic and/or oxygen delivery parameters. A fixed or random effects model was applied to calculate the pooled odds ratio (OR) based on heterogeneity through the included studies. RESULTS: A total of 28 studies with 9,019 patients were included. The pooled data showed that compared with usual care, GDFT reduced the incidence of acute kidney injury (AKI) in critical illness (OR 0.62, 95% confidence interval (CI) 0.47 to 0.80, p< 0.001). Sensitivity analysis with only low risk of bias studies showed the same result. Subgroup analyses found that GDFT was associated with a lower AKI incidence in both postoperative and medical patients. The reduction was significant in GDFT aimed at dynamic indicators. However, no significant difference was found between groups in RRT support (OR 0.88, 95% CI 0.74 to 1.05, p= 0.17). GDFT tended to increase fluid administration within the first 6 h, decrease fluid administration after 24 h, and was associated with more vasopressor requirements. CONCLUSIONS: This meta-analysis suggests that GDFT aimed at dynamic indicators may be an effective way to prevent AKI in critical illness. This may indicate a benefit from early adequate fluid resuscitation and the combined effect of vasopressors.

The furosemide stress test predicts the timing of continuous renal replacement therapy initiation in critically ill patients with acute kidney injury: a double-blind prospective intervention cohort study.

BACKGROUND: Continuous renal replacement therapy (CRRT) remains a crucial treatment for critically ill patients with acute kidney injury (AKI), although the timing of its initiation is still a matter of contention. Furosemide stress testing (FST) may be a practical and beneficial prediction instrument. This research was meant to examine if FST can be used to identify high-risk patients for CRRT. METHODS: This study is a double-blind, prospective interventional cohort study. For patients with AKI receiving intensive care unit (ICU) income, FST was selected with furosemide 1 mg/kg intravenous (1.5 mg/kg intravenous if a loop diuretic was received within 7 days). Urinary volume more than 200 ml at 2 h after FST was FST-responsive, less than 200 ml was FST-nonresponsive. The FST results are kept strictly confidential from the clinician, who decides whether to initiate CRRT based on laboratory testing and clinical symptoms other than the FST data. The FST data are concealed from both the patients and the clinician. RESULTS: FST was delivered to 187 of 241 patients who satisfied the inclusion and exclusion criteria, with 48 patients responding to the test and 139 patients not responding. 18/48 (37.5%) of the FST-responsive patients received CRRT, while 124/139 (89.2%) of the FST-nonresponsive patients received CRRT. There was no significant difference between the CRRT and non-CRRT groups in terms of general health and medical history (P > 0.05). Urine volume after 2 h of FST was considerably lower in the CRRT group than in the non-CRRT group (35 ml, IQR5-143.75 versus 400 ml, IQR210-890; P = 0.000). FST non-responders were 2.379 times more likely to initiate CRRT than FST responders (95% CI 1.644-3.443, P = 0.000). The area under the curve (AUC) for initiating CRRT was 0.966 (cutoff of 156 ml, sensitivity of 94.85%, specificity of 98.04%, P < 0.001). CONCLUSION: This study demonstrated that FST is a safe and practical approach for predicting the initiation of CRRT in critically ill AKI patients. Trial registration www.chictr.org.cn , ChiCTR1800015734, Registered 17 April 2018.

[Determination of glycyrrhizic acid in glycyrrhiza uralensis fisch by fiber optic near infrared spectroscopy].

The objective of this study was to develop a rapid, non-destructive and real-time method for the determination of glycyrrhizic acid in glycyrrhiza uralensis fisch. Near infrared spectra (NIR) in the range of 10 000-4 000 cm(-1) were recorded for the glycyrrhiza uralensis fisch containing glycyrrhizic acid in the content of 0.94 %-3.06%. Calibration models were established using the PLS (partial least squares) and PCR (principle component regression) algorithm. Different spectra pretreatments methods were compared. The study showed that PLS model gave better results than PCR with the correlation coefficient 0.958, SEC 0.179 (standard deviation of the calibration sets) and SEP 0.197 (standard deviation of the prediction sets). Results indicate that fiber optic NIR method can be used to on-line control the valid component in Chinese herbs.

Changes in end-tidal CO2 could predict fluid responsiveness in the passive leg raising test but not in the mini-fluid challenge test: A prospective and observational study.

OBJECTIVE: The objective is to explore the value of end-tidal carbon dioxide (ETCO2) in replacing cardiac index for evaluating fluid responsiveness during the passive leg raising (PLR) test and mini-fluid challenge (mini-FC). METHODS: Patients experiencing septic shock and who were on mechanical ventilation in an intensive care unit were divided into responder and nonresponder groups according to whether their cardiac index increased by more than 10% after the FC. Before and after those tests, the changes in ETCO2, central venous pressure, heart rate, mean arterial pressure, pulse pressure, and cardiac output were recorded. RESULTS: Of the 48 patients in the study, 34 had fluid responsiveness according to the changes in cardiac output or stroke volume. The ΔCI and ΔETCO2 in the responder group were larger than the changes in the nonresponder group during the PLR test (1.1 ± 0.7 vs 0.2 ± 0.4 L/min per square meter, 3.0 ± 3.0 vs 0.5 ± 2.5 mm Hg; P < .05) but not during mini-FC. ΔETCO2 greater than or equal to 5% during the PLR test predicted fluid responsiveness with 93.4% specificity and 75.8% sensitivity in a receiver operating characteristic curve. The area under the curve was 0.849 (95% confidence interval, 0.739-0.930). ΔETCO2 greater than or equal to 3% during the mini-FC predicted fluid responsiveness with 93.4% specificity and 33.3% sensitivity in a receiver operating characteristic curve, and the area under the curve was 0.781 (95% confidence interval, 0.646-0.915). CONCLUSIONS: The changes in ETCO2 may predict fluid responsiveness during the PLR test in patients with septic shock, but similar results were not found with the mini-FC.

[Comparison of the effect of fluid resuscitation as guided either by lactate clearance rate or by central venous oxygen saturation in patients with sepsis].

OBJECTIVE: To compare the efficacy of fluid resuscitation as guided by lactate clearance rate (LCR) and central venous oxygen saturation (ScvO2) in patients with sepsis. METHODS: A prospective randomized control study was conducted. Fifty patients diagnosed with severe sepsis or septic shock from January 2011 to February 2012 in department of critical care medicine of Fourth Hospital of Hebei Medical University were enrolled in the study. The patients were randomly divided into two groups according to the sequence (each n=25): ScvO2 group and LCR group. After ICU admission, the patients were treated symptomatically timely, and fluid resuscitation was started as early as possible according to Surviving Sepsis Campaign guidance for management of severe sepsis and septic shock 2008. Central venous pressure (CVP)≥8 mm Hg (1 mm Hg=0.133 kPa), mean arterial pressure (MAP)≥65 mm Hg and ScvO2≥0.70 served as goal values to accomplish the fluid resuscitation therapy in ScvO2 group, while CVP≥8 mm Hg, MAP≥65 mm Hg, LCR≥10% served as goal value to accomplish the fluid resuscitation therapy in LCR group. The general condition and clinical characteristics on arrival in ICU, changes in CVP, MAP, ScvO2, lactate level and/or LCR before (0 hour) and 3, 6, 72 hours after the start of fluid resuscitation and the other related conditions during the therapy were recorded. RESULTS: There was no significant difference in general data or clinical characteristics before the start of therapy, occurrence of organ dysfunction, or treatment measures during different time periods after start of fluid resuscitation. Compared with the condition immediately before fluid resuscitation, at 3 hours after start of fluid resuscitation, CVP were improved in LCR and ScvO2 groups (8.58±1.17 mm Hg vs. 6.33±1.21 mm Hg, 9.08±2.43 mm Hg vs. 5.33±0.98 mm Hg, both P<0.05); at 6 hours after start of fluid resuscitation, heart rate (HR) and respiratory rate (RR) were lowered in LCR and ScvO2 groups (HR: 96±18 bpm vs. 127±13 bpm, 98±13 bpm vs. 116±19 bpm, RR: 23±3 times/min vs. 33±9 times/min, 24±5 times/min vs. 35±6 times/min, all P<0.05), oxygenation index (PaO2/FiO2) was increased in LCR and ScvO2 groups (179±41 mm Hg vs. 86±21 mm Hg, 202±33 mm Hg vs. 95±17 mm Hg, both P<0.05), and there was no significant difference in MAP in both groups. There was no significant difference in all indexes between two groups. In LCR group, 3 hours after start of fluid resuscitation, lactate level was significantly decreased (2.81±0.18 mmol/L vs. 3.43±1.31 mmol/L, P<0.05). Compared with the value 3 hours after start of fluid resuscitation, LCR was significantly improved at 6 hours and 72 hours after start of fluid resuscitation in LCR group [(42.69±8.75)%, (48.87±9.69)% vs. (20.32±4.58)%, both P<0.05]. Compared with that immediately before fluid resuscitation, ScvO2 was significant improved in ScvO2 group at 3 hours after start of fluid resuscitation (0.65±0.04 vs. 0.53±0.06, P<0.05). There was no significant difference in success rate of fluid resuscitation comparing that of 6 hours and that of 72 hours [6 hours: 72% (18/25) vs. 64% (16/25), χ(2)=0.368, P=0.762; 72 hours: 88% (22/25) vs. 88% (22/25) ,χ(2)=0.000, P=1.000], length of ICU stay (8±3 days vs. 10±4 days, t=0.533, P=0.874), length of hospital stay (29±11 days vs. 35±16 days, t=0.692, P=0.531), improvement rate [84% (21/25) vs. 76%(19/25), χ(2)=0.500, P=0.480] or 28-day mortality [20% (5/25) vs. 28% (7/25), χ(2)=0.439, P=0.742] between LCR and ScvO2 groups. CONCLUSIONS: Both LCR and ScvO2 can be taken as the index in confirming the endpoint of fluid resuscitation for patients with severe sepsis and septic shock. Fluid resuscitation therapy under the guidance of LCR is accurate and reliable in patients with severe sepsis and septic shock.

[Relationship between tumor necrosis factor beta gene polymorphism and acute respiratory distress syndrome after operation for esophageal carcinoma].

BACKGROUND AND OBJECTIVE: A single nucleotide polymorphism of the tumor necrosis factor beta (TNF-beta) gene affected the level of tumor necrosis factor beta and was associated with prognosis of acute respiratory distress syndrome (ARDS). This study was to investigate the association between the TNF-beta and ARDS after operation for esophageal carcinoma. METHODS: Thirty-four patients with and 116 patients without ARDS after radical resection for thoracotomic esophageal carcinoma were recruited in the Fourth Hospital of Hebei Medical University from January 2005 to June 2007. Peripheral blood samples were collected and DNA extracted. TNF-beta genotype was determined by restriction fragment length polymorphism (RPLF). RESULTS: There was no significant difference between the two groups in the TNF-beta genotype and allele frequency (P>0.05). The time of mechanical ventilation was shorter and that of staying in the intensive care unit was longer for ARDS patients with the 1/2 genotype in the TNF-beta than for those with other genotypes (both P<0.05). The frequency of the 1/1 genotype and 1 allele in the TNF-beta was significantly higher in the group of surviving patients with ARDS than in the group of death patients. The odd ratios for mortality of two groups were 16.5 and 11.2, respectively. CONCLUSIONS: TNF-beta did not appear to be a contributing factor influencing the morbidity of the patients with ARDS after operation for esophageal carcinoma, however, it might affect the development and prognosis of ARDS.

[Correlations of preoperative pulmonary function tests for esophageal cancer to postoperative acute respiratory distress syndrome].

BACKGROUND & OBJECTIVE: Acute respiratory distress syndrome (ARDS), a serious postoperative complication of esophageal cancer, has a high mortality rate. Preoperative pulmonary function affects treatment project selection and prognosis prediction. The correlation of preoperative pulmonary function of esophageal cancer to postoperative ARDS has seldom been reported. This study was to analyze their correlation to serve for clinical medicine. METHODS: Clinical data of 1 488 esophageal cancer patients, received esophagectomy from 2000 to 2002 in our hospital, were retrospectively reviewed. The correlations of postoperative ARDS to 3 traditional parameters in pulmonary function test, including forced expiratory volume in the first one second (FEV1%), the ratio of FEV1 to forced vital capacity [(FEV1/FVC)%] and maximal voluntary ventilation (MVV%), and other factors, such as age, sex, operation pattern, preoperative cardiac function, early postoperative intensive care, were analyzed. RESULTS: Of the 1,488 patients, 49 suffered postoperative ARDS. The occurrence of ARDS was negatively related to the interaction of FEV1%, (FEV1/FVC)%, MVV% and age (P=0.001, P=0.005, P=0.048). Of the 49 patients suffered severe preoperative lung function damage, 32 received intensive care right after operation, of whom 2 (6.2%) had ARDS; 5 (29.4%) of the remaining 17 had ARDS. Early postoperative intensive care significantly decreased the occurrence of ARDS (P<0.05). CONCLUSIONS: Traditional pulmonary function test have some correlations to postoperative ARDS. Early intensive care is important to prevent ARDS after operation.